AMCP Position on Transitions of Care

Statement

The Academy of Managed Care Pharmacy (AMCP) recognizes the critical role of pharmacists in ensuring continuity during transitions of care. AMCP strongly supports and advocates for the pharmacist's involvement in collaborative, patient-centered care throughout these transitions.

Background

Transitions of care (TOC) are defined as the movement of patients between health care practitioners, settings, or levels of care as their conditions and care needs change during a chronic or acute illness.¹ Transitions can occur within hospitals, between hospitals, other health care systems, between payers/insurers, or directly at home. Effective and concise transitions are imperative to ensure continuity with quality care. Poor transitions can lead to adverse events that increase hospital readmissions and cost strains on the health care system, limiting patient access.

Pharmacists play an essential role in maintaining the consistency of patients’ medication therapy regimens by analyzing and communicating critical information about drug therapies' safety, effectiveness, and outcomes to other healthcare providers. They also provide education and consultation to patients and caregivers, helping them understand their medications, proper dosing, potential side effects, and the importance of adherence. By facilitating safe and effective medication management during transitions, pharmacists enhance patient outcomes, reduce adverse events, and contribute to a more efficient healthcare system.

Managed care pharmacy is important in ensuring continuity in quality care with TOC. Tools like medication therapy management (MTM) and drug utilization reviews (DURs) are commonly used to prevent a decline in care when patients’ care is transitioned. Managed care promotes collaborative practice, patient education, and adherence support, leading to uninterrupted care when patients change facilities or are sent home to continue their care. With these managed care principles in transitions of care, pharmacists contribute to a more efficient, coordinated, and patient-centered health care system.

Evidence

One in five Medicare patients discharged from the hospital is readmitted within 30 days.² This gap in care emphasizes the need for effective TOC.

Errors can occur during TOC for numerous reasons. Examples include communication breakdown among health care providers, lack of patient education, and medication reconciliation errors. MTM improves patient outcomes involving TOC because documentation of medication lists is a key component of MTM, and pharmacists, including managed care pharmacists, are well-positioned to incorporate this into TOC.

Pharmacists are well-trained in working within interdisciplinary teams to conduct clinical interventions and identify potential barriers to medication access at the receiving facility. Referring patients to home health care services after discharge, especially when new medications are prescribed, can help ease the transition and support medication adjustments. Including pharmacists in transitions of care improves adherence and reduces the risk of medication errors. By assessing the pharmacy formulary, managed care pharmacists also play a crucial role in ensuring patients can access their medications in assisted living or skilled nursing facilities. Additionally, providing clear education to patients and caregivers at discharge is essential. Discharge summaries or transition plans should include detailed medication instructions to ensure continuity of care.

References

Agency for Healthcare Research and Quality. Transitions of care. Updated 2024. Accessed December 23, 2024.
Pharmacists Are Vital to Transitions of Care. Pharmacy Times. Published February 2023. Accessed December 23, 2024.